Provider Demographics
NPI:1700076080
Name:PRIDMORE, GROVER PAUL (MED, LMHC)
Entity type:Individual
Prefix:
First Name:GROVER
Middle Name:PAUL
Last Name:PRIDMORE
Suffix:
Gender:M
Credentials:MED, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 W IVY AVE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-2049
Mailing Address - Country:US
Mailing Address - Phone:509-322-0993
Mailing Address - Fax:
Practice Address - Street 1:1008 W IVY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2049
Practice Address - Country:US
Practice Address - Phone:509-322-0993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9746101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1417088642Medicare UPIN